Jennifer L. Melville

Depressive Disorders During Pregnancy: Prevalence and Risk Factors in a Large Urban Sample

OBJECTIVE: To estimate the prevalence of major and minor depression, panic disorder, and suicidal ideation during pregnancy while also identifying factors independently associated with antenatal depressive disorders. METHODS: In this prospective study, participants were 1,888 women receiving ongoing prenatal care at a university obstetric clinic from January 2004 through January 2009. Prevalence of psychiatric disorders was measured using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria based on the Patient Health Questionnaire. Multiple logistic regression identified factors associated with probable major depressive disorder and any depressive disorder. RESULTS: Antenatal depressive disorders were present in 9.9% with 5.1% (97) meeting criteria for probable major depression and 4.8% (90) meeting criteria for probable minor depression. Panic disorder was present in 3.2% (61), and current suicidal ideation was reported by 2.6% (49). Among patients with probable major depression, 29.5% (28) reported current suicidal ideation. Psychosocial stress (odds ratio [OR], 1.29; 95% confidence interval [CI], 1.21–1.36), domestic violence (OR 3.45; 95% CI 1.46–8.12), chronic medical conditions (OR 3.05; 95% CI 1.63–5.69), and race (Asian: OR 5.81; 95% CI 2.55–13.23; or African American: OR 2.98; 95% CI 1.24–7.18) each significantly increased the odds of probable antepartum major depressive disorder, whereas older age (OR 0.92; 95% CI 0.88–0.97) decreased the odds. Factors associated with odds of any depression were similar overall except that Hispanic ethnicity (OR 2.50; 95% CI 1.09–5.72) also independently increased the odds of any depression. CONCLUSION: Antenatal major and minor depressive disorders are common and significantly associated with clinically relevant and identifiable risk factors. By understanding the high point prevalence and associated factors, clinicians can potentially improve the diagnosis and treatment rates of serious depressive disorders in pregnant women. LEVEL OF EVIDENCE: II

Incontinence severity and major depression in incontinent women.

Objective: Research has shown an association between urinary incontinence and depression. Studies that use community-based samples and major depressive disorder diagnostic criteria are needed. The objective of this study was to estimate the prevalence of and factors associated with major depression in women with urinary incontinence. Methods: We conducted an age-stratified postal survey of 6,000 women aged 30–90 years. Subjects were randomly selected from enrollees in a large health maintenance organization in Washington state. Main outcome measures were prevalence of current major depression and adjusted odds ratios for factors associated with major depression in women with urinary incontinence. Results: The response rate was 64% (n = 3,536) after applying exclusion criteria. The prevalence of urinary incontinence was 42% (n = 1,458). The prevalence of major depression was 3.7% (n = 129), with 2.2% in those without incontinence versus 6.1% in those with incontinence. Among women with incontinence, major depression prevalence rates differed by incontinence severity (2.1% in mild, 5.7% in moderate, and 8.3% in severe) and incontinence type (4.7% in stress, 6.6% in urge/mixed). Obesity (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.3–4.0), current smoking (OR 2.7, 95% CI 1.5–4.9), lower educational attainment (OR 2.0, 95% CI 1.2–3.3), moderate incontinence (OR 2.7, 95% CI 1.1–6.6), and severe incontinence (OR 3.8, 95% CI 1.6–9.1) were each associated with increased odds of major depression in women with urinary incontinence, controlling for age and medical comorbidity. Compared with women with incontinence alone, women with comorbid incontinence and major depression had significantly greater decrements in quality of life and functional status and increased incontinence symptom burden. Conclusion: Women with moderate-to-severe urinary incontinence should be screened for comorbid major depression and offered treatment if depression is present. Level of Evidence: II-2

Fecal incontinence in primary care: prevalence, diagnosis, and health care utilization.

OBJECTIVE We sought to estimate the frequency of self-reported fecal incontinence (FI), identify what proportion of these patients have a diagnosis of FI in their medical record, and compare health care costs and utilization in patients with different severities of FI to those without FI. STUDY DESIGN Patients in a health maintenance organization were eligible and 1707 completed a survey. Patients with self-reported FI were assessed for a diagnosis of FI in their medical record for the last 5 years. Health care costs and utilization were obtained from claims data. RESULTS FI was reported by 36.2% of primary care patients, but only 2.7% of patients with FI had a medical diagnosis. FI adversely affected quality of life and severe FI was associated with 55% higher health care costs (including 77% higher gastrointestinal-related health care costs) compared to continent patients. CONCLUSION Increased screening of FI is needed.

Psychosocial impact of serological diagnosis of herpes simplex virus type 2: a qualitative assessment

Objectives: To assess the emotional and psychosocial responses to a serological diagnosis of HSV-2 infection in individuals without previous history of genital herpes. Methods: 24 individuals who had a positive HSV-2 serology by western blot and no clinical history of disease were recruited from four clinics (sexually transmitted disease, maternal and infant care, family medicine, and virology research) over a 10 month period. In-depth qualitative interviews were conducted to elicit an individual’s responses to the HSV-2 diagnosis. Results: Three categories of themes were identified from the interviews. Short term emotional responses included surprise, denial, confusion, distress, sadness, disappointment, and relief to know. Short term psychosocial responses included fear of telling sex partners, anger at the source partner, guilt about acquiring or transmitting, and concern about transmitting to a child. Perceived ongoing responses included fear of telling future partners, concern about transmitting to a sex partner, feeling sexually undesirable, feeling socially stigmatised, feeling like “damaged goods,” sex avoidance due to social responsibility, fear of transmitting to a newborn, and relationship concerns relating to the diagnosis. Conclusions: Individuals exhibit strong emotional and psychosocial responses to a serological diagnosis of HSV-2 infection. Many of the negative responses may be time limited and influenced by factors that are potentially amenable to counselling.

Major depression and urinary incontinence in women: temporal associations in an epidemiologic sample

OBJECTIVE To determine whether: (1) major depression is associated with increased risk for onset of urinary incontinence, and (2) urinary incontinence is associated with increased risk for onset of depression. STUDY DESIGN Longitudinal cohort study of female Health and Retirement Study participants completing baseline interviews at Wave 3 (1996-1997) and follow-up interviews at Waves 4-6 (1998-2003). RESULTS In a cohort of 5820 women with a mean age 59.3 (+/- 0.5) years, 6-year cumulative incidences of depression and incontinence were 11% and 21%, respectively. Major depression was associated with increased odds of incident incontinence (adjusted odds ratio, 1.46; 95% confidence interval, 1.08-1.97) during follow-up compared with those without major depression at baseline. Conversely, incontinence was not associated with increased odds of incident depression (adjusted odds ratio, 1.03; 95% confidence interval, 0.75-1.42) compared with those without incontinence at baseline. CONCLUSION Major depression predicted onset of urinary incontinence in a population-based sample of at-risk, community-dwelling women. Incontinence did not predict onset of depression.

Improving care for depression in obstetrics and gynecology: a randomized controlled trial.

OBJECTIVE: To evaluate an evidence-based collaborative depression care intervention adapted to obstetrics and gynecology clinics compared with usual care. METHODS: A two-site, randomized controlled trial included screen-positive women (Patient Health Questionnaire-9 score of at least 10) who met criteria for major depression, dysthymia, or both (Mini-International Neuropsychiatric Interview). Women were randomized to 12 months of collaborative depression management or usual care; 6-month, 12-month, and 18-month outcomes were compared. The primary outcomes were change from baseline to 12 months in depression symptoms and functional status. Secondary outcomes included at least 50% decrease and remission in depressive symptoms, global improvement, treatment satisfaction, and quality of care. RESULTS: Participants were, on average, 39 years old, 44% were nonwhite, and 56% had posttraumatic stress disorder. Intervention (n=102) compared with usual care (n=103) patients had greater improvement in depressive symptoms at 12 months (P<.001) and 18 months (P=.004). The intervention group compared with usual care group had improved functioning over the course of 18 months (P<.05), were more likely to have at least 50% decrease in depressive symptoms at 12 months (relative risk [RR] 1.74, 95% confidence interval [CI] 1.11–2.73), greater likelihood of at least four specialty mental health visits (6-month RR 2.70, 95% CI 1.73–4.20; 12-month RR 2.53, 95% CI 1.63–3.94), adequate dose of antidepressant (6-month RR 1.64, 95% CI 1.03–2.60; 12-month RR 1.71, 95% CI 1.08–2.73), and greater satisfaction with care (6-month RR 1.70, 95% CI 1.19–2.44; 12-month RR 2.26, 95% CI 1.52–3.36). CONCLUSION: Collaborative depression care adapted to womens health settings improved depressive and functional outcomes and quality of depression care. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01096316. LEVEL OF EVIDENCE: I

Racial differences in the prevalence of antenatal depression

OBJECTIVE This study examined whether there were racial/ethnic differences in the prevalence of antenatal depression based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria in a community-based sample of pregnant women. METHOD Data were drawn from an ongoing registry of pregnant women receiving prenatal care at a university obstetric clinic from January 2004 through March 2010 (N =1997). Logistic regression models adjusting for sociodemographic, psychiatric, behavioral and clinical characteristics were used to examine racial/ethnic differences in antenatal depression as measured by the Patient Health Questionnaire. RESULTS Overall, 5.1% of the sample reported antenatal depression. Blacks and Asian/Pacific Islanders were at increased risk for antenatal depression compared to non-Hispanic White women. This increased risk of antenatal depression among Blacks and Asian/Pacific Islanders remained after adjustment for a variety of risk factors. CONCLUSION Results suggest the importance of race/ethnicity as a risk factor for antenatal depression. Prevention and treatment strategies geared toward the mental health needs of Black and Asian/Pacific Islander women are needed to reduce the racial/ethnic disparities in antenatal depression.

Diabetes and Depression in Pregnancy: Is There an Association?

BACKGROUND Prior studies have reported inconsistent findings regarding the association of antenatal depression with pregnancy-related diabetes. This study examined the association of diabetes and antenatal depression. METHODS We conducted a cross-sectional analysis of baseline data from a prospective cohort study of pregnant women receiving prenatal care at a single University of Washington Medical Center clinic between January 2004 and January 2009. The primary exposure was diabetes in pregnancy (no diabetes, preexisting diabetes, or gestational diabetes [GDM]). Antenatal depression was defined by the Patient Health Questionnaire-9 (PHQ-9) score or current use of antidepressants. Antenatal depression was coded as (1) any depression (probable major or minor depression by PHQ-9 or current antidepressant use) and (2) major depression (probable major depression by PHQ-9 or current antidepressant use). Logistic regression was used to quantify the association between diabetes in pregnancy and antenatal depression. RESULTS The prevalences of preexisting diabetes, GDM, any antenatal depression, and major antenatal depression were 9%, 18%, 13.6%, and 9.8%, respectively. In the unadjusted analysis, women with preexisting diabetes had 54% higher odds of any antenatal depression compared to those without diabetes (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.08-2.21). After adjusting for important covariates the association was attenuated (OR 1.16, 95% CI 0.79-1.71). Results were similar for antenatal major depression. GDM was not associated with increased odds for any antenatal depression or antenatal major depression. CONCLUSIONS Neither preexisting diabetes nor GDM was independently associated with increased risk of antenatal depression.

Prevalence and correlates of suicidal ideation during pregnancy

Data are scarce regarding the prevalence and risk factors for antenatal suicidal ideation because systematic screening for suicidal ideation during pregnancy is rare. This study reports the prevalence and correlates of suicidal ideation during pregnancy. We performed cross-sectional analysis of data from an ongoing registry. Study participants were 2,159 women receiving prenatal care at a university obstetric clinic from January 2004 through March 2010. Multiple logistic regression identified factors associated with antenatal suicidal ideation as measured by the Patient Health Questionnaire. Overall, 2.7% of the sample reported antenatal suicidal ideation. Over 50% of women who reported antenatal suicidal ideation also reported major depression. In the fully adjusted model antenatal major depression (OR = 11.50; 95% CI 5.40, 24.48) and antenatal psychosocial stress (OR = 3.19; 95% CI 1.44, 7.05) were positively associated with an increased risk of antenatal suicidal ideation. We found that being non-Hispanic White was associated with a decreased risk of antenatal suicidal ideation (OR = 0.51; 95% CI 0.26–0.99). The prevalence of antenatal suicidal ideation in the present study was similar to rates reported in nationally representative non-pregnant samples. In other words, pregnancy is not a protective factor against suicidal ideation. Given the high comorbidity of antenatal suicidal ideation with major depression, efforts should be made to identify those women at risk for antenatal suicidal ideation through universal screening.

Can mentors prevent and reduce burnout in new chairs of departments of obstetrics and gynecology : results from a prospective, randomized pilot study

OBJECTIVE This study assessed burnout in new chairs of obstetrics and gynecology and whether mentoring by experienced chairs would prevent or reduce burnout. STUDY DESIGN We performed a year-long prospective, randomized trial. Questionnaires were sent to new chairs to obtain demographic information and to identify need for mentoring and level of burnout. Fourteen chairs in the intervention group selected a mentor; 13 chairs served as controls. After 1 year, questionnaires were completed to determine stress and burnout and the impact of mentoring. RESULTS Financial issues were the major stressors. New chairs identified human resources, finances, and relationships with school leaders as areas of greatest need for mentoring. Few chairs exhibited burnout. No differences were observed in burnout at the start of the study or after 1 year in the study groups. Mentors and new chairs found the mentoring relationship difficult to establish and maintain. CONCLUSION Long-distance mentoring by experienced chairs did not alter burnout in new chairs of obstetrics and gynecology. Local mentors appear to be more effective.